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In this House, we have some extraordinary women who have overcome the barriers. In addition to being Peers, they run families and organisations. They are on the boards of companies, charities, voluntary organisations et cetera. Not only should we be proud of these women, but we should use them whenever and wherever possible as role models to nurture and foster change in our society, so that the full participation of women in public life becomes the norm rather than the exception. I believe that that is our duty. The challenge that we have discussed today is an issue not only for the present but also for future generations, who need to see role models in these positions so that they can be inspired to step forward.
Health: Asthma
3 pm
Viscount Simon asked Her Majesty’s Government what steps they are taking regarding the prevalence and treatment of asthma.
Baroness Thornton: I suggest that we adjourn for five minutes.
[The Sitting was suspended from 3.01 to 3.06 pm.]
Viscount Simon: As someone who has severe brittle asthma, and who can have a serious attack within a few seconds following the inhalation of certain triggers, I am pleased to have secured this Question for Short Debate on asthma. Four and a half million—that is, one in 11—people in England are currently receiving
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This Government have delivered some real improvements for people with asthma. In particular, the smoking ban allows us to work and socialise in smoke-free environments and will help to reduce the impact of asthma in the future. But we must not be complacent. Asthma UK has estimated that, with correct asthma management, up to 90 per cent of deaths from asthma, and up to 75 per cent of hospital admissions due to asthma attacks, could be prevented.
Today I want to highlight the fact that much more needs to be done and to urge the Government to focus on driving up standards of asthma care and treatment by introducing a national clinical strategy for asthma. Many people assume that asthma is not serious because it should be possible to control in most cases, and most people have little conception of what an asthma attack is like. But asthma is serious. On average, one person dies from asthma every seven hours in the UK. Hospital admissions for asthma are increasing, having previously declined. Too many people suffer in silence with symptoms that are bad enough to cause them difficulty sleeping and to interfere with their usual activities. An Asthma UK survey of more than 1,000 people with asthma found that 69 per cent of people did not have their asthma under control as defined by Royal College of Physicians standards.
Asthma UK’s recent Wish You Were Here? report identified a postcode lottery in hospital admissions. Most shockingly, children living in Liverpool have an almost eight times higher chance of emergency hospital admission for asthma than children living in Richmond and Twickenham. Asthma is one of the top five causes of emergency hospital admissions among children in England. The knock-on effect can be severe, particularly if children have to miss school through asthma attacks and frequent appointments with specialists. Without adequate support, asthma damages their life chances.
The postcode lottery also applies to people of all ages living in neighbouring areas. There is almost a threefold difference in admissions between adjacent PCTs. Afro-Caribbeans are twice as likely, and south Asians three times as likely, as white people to end up in hospital with an asthma attack, despite small differences in the rates of asthma within these communities. Outcomes are worse in poorer areas, with 86 per cent of spearhead PCTs having higher than average emergency admissions for asthma.
An asthma attack is a frightening and distressing experience, not only for the patient but also for their family. A person’s chances of accessing treatment good enough to put an end to the attack and keep them out of hospital should not depend largely on where they live. However, we should be optimistic about what, after improvements, the NHS could achieve through a sustained focus on asthma.
A survey showed that 20 per cent of nurses with lead responsibility for respiratory care have no accredited training in asthma. People with asthma say that the
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An acute NHS health trust report highlighted difficulties both in identifying patients who are frequently admitted with asthma attacks and in following people up after hospital admissions. Healthcare professionals with a special interest in asthma and respiratory conditions report that the clinical asthma guidelines developed by the British Thoracic Society are still not widely used. They also say that asthma-specific recommendations in the National Service Framework for Children, Young People and Maternity Services, published four years ago, are not being widely implemented. This may help to explain why asthma is still one of the top five causes of emergency admissions among children.
Although there is clear need for improvement, there are also some fantastic initiatives that could make a huge difference if there was a national strategy to replicate them elsewhere. Following funding provided by Asthma UK, Liverpool PCT, which has the highest admissions for asthma in England, is developing a whole-systems approach involving all the relevant organisations, including the PCT, the local authority and the local education authority, to improve standards and quality of care for people with asthma. The approach aims to empower both people with asthma and healthcare professionals to manage asthma effectively and improve the quality of services provided, with the overall aim of reducing emergency hospital admissions for asthma in Liverpool. Neighbouring PCTs in Oldham and Knowsley have recently joined in this major initiative in the north-west of England.
It costs three and a half times as much to treat someone who has an asthma attack as it does to care for someone whose asthma is well managed. That is important. Surely the money wasted on preventable emergency admissions would be better spent getting asthma management right, quite apart from the distress to patients and their families, which can and should be avoided.
Despite all the problems that I have spoken about today, I remain optimistic that we can drive up standards of asthma management to the level of the very best. Huge gains can be made, but that will happen only if the NHS makes asthma a sustained priority. This focus must include a national clinical strategy for asthma to drive up standards of asthma care, rather than the current patchwork of poorly implemented standards and guidelines.
Department of Health officials are currently finalising a national clinical strategy for chronic obstructive pulmonary disease, which will include initiatives that
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3.14 pm
Lord Colwyn: I thank the noble Viscount, Lord Simon, for bringing the problems of asthma to our attention again. I have probably never heard a more dramatic introduction to a short debate in my many years in your Lordships’ House. As a sufferer of asthma from a variety of causes—perfume is probably the worst to him—he must be admired for the normality of his life and for his tireless campaigning for fellow asthmatics.
I was privileged to sit with the noble Viscount on the Science and Technology Committee when we produced the report on allergy, which was published just over a year ago and debated in this House on 8 May this year. The report was useful and the Government’s response has been encouraging, but the required action needs more time and more money.
I shall not repeat too many figures, but they are important. About 20 million children and adults in the UK suffer from a form of allergy. More than 5 million of them have asthma, of which 1.1 million are children. Between April 2006 and March 2007, there were 67,077 emergency hospital admissions for people experiencing an asthma attack, 40 per cent of whom were children under 15. A simple allergy can be an early step on the allergic march towards much more serious allergies. The critical impact of allergy on health and the quality of life and its potential to cause fatalities, usually in older children and adolescents, should not be ignored. The prospects of unexpected allergic catastrophe or anaphylactic death are real for many families and should not be underestimated.
Good health and the ability to fight off disease are a function of the immune system. We read references daily to how that can be improved. It has been suggested that pregnant women who lead a sedentary lifestyle increase the risk of asthma for their children. Recent studies have shown that levels of vitamin D, which is found in food such as oily fish and is boosted by natural sunlight, can influence the development of a child’s lungs and immune system while in the womb. There is increasing evidence that an infection with gut parasites may protect against asthma and allergy. A recent study, funded by Asthma UK, showed that children born to mothers who had a low intake of vitamin E during pregnancy were five times more likely to have asthma than children whose mothers had eaten a diet high in vitamin E. There is also a possible link between asthma and obesity. The number of people with both problems has soared in recent decades. There are many more possible links between asthma, diet, rubbish collection and storage, pets, environmental issues, pollution and regional variations; I would need a whole hour to myself to cover them all, but they all carry an increased risk to the respiratory system.
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In 2007, a person was admitted to hospital every eight minutes because of their asthma. A possibly defective gene has been blamed. Scientists have identified a cold-fighting protein that asthmatics lack. The common cold triggers about 85 per cent of asthma attacks in children and 60 per cent of those in adults. We need accurate data, so I repeat the Science and Technology Committee’s recommendation to the Department of Health, which was that the systemised nomenclature of medicine system, supported by appropriate training, should ensure efficacy as a simple, consistent classification system to record allergic disease, monitor its prevalence and inform the commissioning of allergic services.
Patients and the public should be better informed about allergy and allergic asthma. The ability to make an accurate diagnosis should be improved and there should be better, more specialised training for healthcare professionals. Poor knowledge of allergic conditions stems from the lack of an integrated and holistic approach to treatments. People with multiple allergies tend to see multiple specialists for multiple treatments, rather than a single allergy specialist.
There is a clear need for more research into the causes of allergy and asthma and into the clinical effectiveness of different forms of treatment. Work is proceeding on the definition of susceptibility genes for asthma and related phenotypes by positioning cloning approaches and recognising that pharmacogenetic approaches may be beneficial in managing patients. More diagnostic testing is needed, and services in both primary and secondary care should be improved. Only then will people with asthma and allergic conditions get the treatment that they need. I hope that the noble Viscount keeps up the good work.
3.19 pm
Baroness Greengross: One of the most courageous children I have ever known, for whom I had responsibility for a short while, had serious asthma. He was in this country from Germany with me. He longed for a normal life and he did everything that he could to have one. I longed for access to specialist care and the certainty that I could reach it if he had an attack. There were no specialists where we were and the GP did not have specialist knowledge.
One priority is to ensure that people have the name of a GP who specialises in asthma care. I think that only 13 per cent of people have the comfort of knowing that that is available. A survey has shown that 20 per cent of asthma nurses, who are expected to diagnose asthma and to give follow-up treatment without medical input, have not had accredited training. People with asthma have told us that the recent decline in the number of specialist asthma nurses has affected the quality of care that they receive. This is at a time when the number of people suffering from asthma is increasing rapidly. I hope that the Government will do something to make this a priority in the very near future.
3.21 pm
Baroness Tonge: I thank the noble Viscount for securing the debate and congratulate him on timing an asthma attack so perfectly that we really need say no
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When I was a child, the only I person I knew who had asthma was my best friend. Every winter, I spent many weeks sitting by her bedside, rather as I sat by the noble Viscount a few minutes ago, watching her struggle for breath after contracting a cold that had precipitated her asthma. We spent many hours playing board games in her bedroom. I have to say that that was when we were not in my bedroom playing board games, because I was confined to bed with recurrent ear infections following colds. We both suffered, but I do not think that anything was quite as bad as asthma. I am well aware of what it must be like.
We have all seen the increase in asthma. In my childhood, my friend was the only person I knew who had bad asthma, but among my children’s generation there seemed to be huge numbers of children with asthma. On holiday in Spain as a teenager, one of my daughter’s friends died in an asthma attack because she could not get to a hospital in time. That was not very long ago.
Nowadays, as we have heard from the noble Lord, Lord Colwyn, schoolteachers seem to have many children with asthma in each class. They are well aware of it. Asthma has certainly been on the increase: we are told that there are now two or three times as many sufferers as there were 50 years ago. No one is really sure of the reason for that, although the noble Lord, Lord Colwyn, dealt with those aspects very adequately. It was interesting to hear him speak.
The smoking ban will help, as air pollution was always a factor. When I was a junior doctor and a GP, the fashionable thinking was that asthma was due to house mites. The increase in the number of cases of asthma has flattened recently and I wonder whether that is linked to the fashion for wooden floors as opposed to thick carpets. That may have contributed to the flattening of the graph for asthma.
Some 4.5 million people in this country have asthma, which is a lot of people. It is one of the most common long-term conditions that doctors and nurses have to deal with. Ten per cent of those 4.5 million people have very severe difficulties and very bad asthma. People may have seen the Royal College of Physicians survey, which says that 69 per cent of people with asthma do not have their symptoms under proper control. Some 38 per cent reported difficulty sleeping in the past month and 33 per cent reported interference with their usual activities in the past month. It is a serious, life-disrupting disease, with which people must live all their lives.
There were 1,199 deaths from asthma in 2006. That is more than the number of deaths from cervical cancer and testicular cancer combined. There have been many initiatives and a lot of publicity about cervical cancer and we are fortunate that the Government have made great strides and that the health service is doing a lot about it, but there are more deaths from
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As we heard from the noble Viscount, people from the worst areas of Liverpool are more likely to go into hospital than are people in my former constituency of Richmond, which in some table or other once was regarded as the most highly educated and most well-off constituency in England. The reason why people there have better control of asthma is probably that patients’ parents and relatives and the patients themselves are so much more demanding and expect so much more in preventive care from clinicians.
What are some of the things that we should be doing to help those people? First, we need a personal action plan. It is terribly important that a doctor sits down with an asthmatic patient and works out what is going to happen to them and what they need. The noble Viscount clearly demonstrated that he has a personal action plan. He knows what to do and he does not need anyone to interfere. He knows that, if he does the right things, it will get better. Many people do not have that, but they need it. However, if that is to be the case, we will need many more specialist GPs and nurses in the community. Please, please can we have more training for doctors and nurses? In particular—the Minister will know about this because I am always beefing on about it—we need more community nurses who can deal with and have specialist training in long-term conditions. Asthma is one of them.
Every patient should have access to a personal care plan and to specialist GPs and nurses. They should be able to see a doctor who knows about the condition, whether or not that doctor is in their own practice. We also need a dedicated national strategic framework; every other country in the British Isles has one, but England does not. I know that things have been laid down on asthma in the children, young people and maternity services framework, but asthma is such a common long-term condition that it needs a strategic framework of its own. In some ways, it is great to have targets and frameworks, but the conditions that are left out get left behind, because PCTs and clinicians concentrate on the ones for which figures are collected. We must be very careful to ensure that asthma is not left out.
I have some questions for the Minister. What national initiatives are planned for the treatment of asthmatics? How will the Government deal with the postcode lottery that the noble Viscount mentioned, comparing Liverpool and Richmond, for example? When will we have a national strategic framework for asthma, together with training for doctors and nurses, so that people up and down the country, children and adults, can deal with their asthma, as has the noble Viscount this afternoon, and not have to be unnecessarily admitted to hospital?
3.30 pm
Earl Howe: The noble Viscount, Lord Simon, has done us a great service by tabling this debate on a subject of which, sadly for him, he has first-hand experience. I congratulate him on a trenchant speech. It highlighted the main problem with asthma as a
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The rate of childhood asthma is higher in England than almost anywhere else in the world. We can and should draw attention to the prevalence statistics, but it is perhaps even more important to talk about the reality of living with asthma, which the noble Viscount was perhaps too stoical to refer to in any graphic detail, but which, as many of us will know from our families and friends, can be truly miserable and often an extremely frightening part of daily living.
Service provision is, I fear, a lottery; Asthma UK has published unequivocal data to demonstrate that. One of the main markers of that lottery is hospital admissions, where we see a vast disparity between different regions of the country, not least where it comes to children. The chances of a child being hospitalised for asthma as an emergency admission is more than twice as high in the north-west than it is in the east of England. In the east Midlands, on the other hand, the rate is 21 per cent below the average. Those disparities cannot simply be attributed to socio-economic factors; they must also reflect differences in service provision. Quite rightly, Asthma UK has been urging the Government and the NHS to do something about that.
Part of the problem—in fact, a major part, as the noble Viscount mentioned—is the absence of national standards. Without such standards, patients are missing out in a big way, but the NHS is also missing out on millions of pounds in potential savings. Asthma UK tells me that asthma-related emergency hospital admissions cost the NHS £61 million a year and that three-quarters of those admissions are avoidable. Even if it has exaggerated the scope for financial saving—I do not think that it has—we are still talking about tens of millions of pounds of unnecessary cost. Once someone has a serious asthma attack, the cost of looking after him is three and a half times more than if the attack had been prevented. As we have heard, there are 4.5 million people with asthma in England. More than two-thirds of asthmatics who were surveyed by Asthma UK said that their symptoms were not under control.
An NSF or national clinical strategy would benefit an awful lot of people. I understand that we are the only western or developed country that has nothing of that nature. The last that we heard in a Lords Parliamentary Answer was that an NSF was not even in development. Why is that? Wales, Scotland and Northern Ireland have their own guidelines and the British Thoracic Society has issued guidelines, so it should not be too big a step to produce a national clinical strategy for England.
As a start, we need to look at basic things such as personal asthma action plans. We know that where someone has one of those plans, setting out what treatment regime is appropriate to them and exactly when they should seek help, they are four times less likely to be admitted to hospital as an emergency case. However, as the noble Baroness, Lady Tonge, told us,
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There are particular difficulties with people who have severe asthma or asthma that is difficult to control. Acute trusts have told Asthma UK that they find it hard to identify patients who have been admitted to hospital on a frequent basis, which seems extraordinary. They also find it difficult to follow those people up after they have been to hospital.
I would be glad if the Minister could say something about specialist training in asthma for GPs and nurses. For many patients, access to an asthma specialist is difficult to achieve. Only 13 per cent of people with asthma have been offered the name of a GP specialising in asthma in their area. Asthma UK tells me that it is particularly concerned that many healthcare professionals who treat asthma have not had adequate training. The noble Baroness, Lady Greengross, referred to the 2006 study by Education for Health and Edinburgh University, which found that 20 per cent of asthma nurses have not had any accredited training. Again, that seems most surprising. On top of that, there has been a decline in their numbers, which, not surprisingly, patients say has affected the quality of care that they receive. That is also something that an NSF could address.
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